GW1--06667_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well`Contractor Information:
' Ca\/1 S Ee r� '
IY 19 WATG1tzUlilEs. ::
Well�C+onttrractor�Name FROM TO DESC�RI�P^TIONtn
A` -3S) ft. 5 f: �u•_7Cj�NVD
NC Well-Contractor Certification Number
I� tom, '15,"OUTER,CASING(for multi casedWills):ORLINER(itap Hea de)
�''�r 911 Pr ' 1�"iJJ�i► !/off I/i 1i `11 { Pomp )A Y{ ne FROM _TO
DIAMETER THICKNESS 11n1�1�ATERiAL
ii4Na e ►t Ui v r I w7 r1 1Ir Ji 1 I'4 ( r 0 ft.• 16Y ft. (fit I f i, in. 1 lie.
Company Name �p (
r�3/�j� -��, ` 1b::INNER CASING.OIt':TUBING(geothermal closed400p)
2.Well Construction Permit#.{ 1 )''s (.lt. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.VIC,County,State,Variance,eic.) ft. . ft. 1 in
3.Well Use(check well use): it it in.
i
Water Supply Well: 17c SCREEN
' FROM 'TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
• industrial/Commercial Residential Water-Supply(shared)
"1.8..GROUT ... I
• Iirigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. W ft. 12, 9 R t(.UL
Monitoring DRccovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge EjGroundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK Of applicable): .
ty FROM TO MATERIAL. EMPLACEMENT'METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology .Subsidence Control ft. ft. I:
Geothermal(Closed Loop) OTracer •20.DRILLING.LOG(attachadditional`aheetsiifilecessaiy): ... .
Geothermal(Heating/Cooling Return) •Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,gram size.etc.)
q 0 r �t. � ft. f I�uv�I
4.Date Well(s)Completed:"I 1 V I 1/ Well ID# ''AD ft. 10�t't. C ftt
5a.Well Location: it. ft. : - T
(l'J/� ' , t`� (®� ��f���� 0 it
i iJlkt 1 4. L Y t2iS.sa�t (�L 4 aiNS� ft. ft. I t N-s .c...'Q. %rI , y
Facility/OwnerIV�aJmc tJ Facility IU#(if applicable) ft. ft.
r)I`� iv '�Y r,,e ,� q �fQ�lf NOV 0 RQ7q
F kArinP-{R.V 1. . I ititi t'1 , lid) P ft. ft.
Physical Address,City,and Zip,
J (/ 3/� t 1,1
ft. ft. "'""' ^•.
wood U q' '�f W1 21 REMARI{5:. : 1
County 'J Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
• (if well field,one lat/long is sufficient)
' ` 22.Certification:. /
35.59LI N �7 .el W 21. g jiq �
,� 7
6.Is(are)the wells) Permanent or QlTemporary Signature ofCertrfied Well Contractor ' Date
By signing this form,I hereby coil*that the well(s)was(here)constricted in accordance
7.Is this a repair to an existing well: QIYes or ONo with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Phis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the xeli owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: COOS (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: i
10;Static water level-below top:of casing: COLA) (ft.), Division of Water Resoui•ces,iuformation Processing"Unit,
i/outer level is noave casing,use"1- tt _ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CO (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1- above,also submit one copy of this form within 30•days of'completion of well
construction to the following: •
(i•e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: f 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .3 l' Method of test: 7., 1i n i trS 24c.For Water Supply&Injection'Wells: In addition to sending the form to
.1 ,�np _1L�•�A the address(es) above, also'submit'One'copy of this form within 30 days of
i13b.Disinfection type: I Amount: �/`�i ,s t cnmpJelinn nt well construction to Mc county health tlepartment of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality•Division of Water Resources ' Revised 2-22-2016